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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA k Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address E City_-STi12/CJ Lot Size A PM Owner's Name EL ��.�1�4 { ss PO 804 31-0 Id E5. 913.03 Phone Sa-3 Contractor ID is, M" Address�j /V,_q�j�L License �- No. `�9�1.7 {, _Phone fps-- TYPE OF WELL/PUMP: NEW WELL dam- __yyECL"REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPI. AIR ❑ OTHER ❑ -------_� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL -+OTHER WELL PITS/SUMPS .rte I I INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavationi� EJDomestic/Private ❑ V Gravel Pack ❑ Trac T I Dia. of Well Casing- F1 Public ypefof Casing -_ ._Specifications 17 Other 0 Delta Depth of Grout Seal 1 i Irri ation TypeofGrout s g' —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. v SWork.Done. r Destruction ❑ Well Diameter Sealing Material Itop 50,)- „ tate 1 -- � Depth —Filler 4haterial.(Below 50'), TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION - DEST.RUCTION 1 1 INo septic system permitted if public sewer is A o available within 200 feet.) Installation will serve:, Residence Commercial` Other ✓ _�' s Number of living units: _._,L Number of bedrooms_ 2- Character-of,soil-to•a-depth.of-3,1ee_t:,. J SEPTIC TANK �- s Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LIN a !'1� ' ' Method of Disposal Distance to nearest: WeljFoundation Property Line LEACHING LINEk L5”No. & Length,of_Eines� Total length/size 7 FILTER BED ❑ Distance to nearest: Well - � Foundation 30 ' Property Line 2�' T z, , SEEPAGE PITSrr I depth Size Number � SUMPS Cl Distance to nearest: Wellff�D`f Foundation - property Line 10.+ DISPOSAL PONDS ❑ # I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature M u certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." The must-call for all required inspections.-Complete drawing-on reverse-side.- Signed side`Signed X Title: - w Date: FOR DEPARTMENT USE ONLY y Application Accepted by Date Pit or Grout Inspection by Date ' � - Final inspection by R Date � Additional Comments: -- I ❑ Stk 466-6781 0 Lodi 369-362 a ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMfTTED K INFO RECEIVED BY DATE PERMIT'No. + EH 13-21 iREV.1in5i EH 14-26